The crises are not always of the same severity, and consequently do not always produce the same effects on the general system. The vomiting and pain may be so severe that complete collapse is produced by the uncontrollable vomiting and the intolerable agony. As a rule, the crises become milder as the spinal disease advances.

If

Under

The crises of tabes dorsalis are paroxysmal, spasmodic, and gastralgic. The nerves and the muscle of the stomach are affected to a much greater degree than is secretion. There is pain, loss of appetite, and cramps, but the state of secretion is determined to a greater extent by the antecedent state of the mucous membrane than it is by the spinal sclerosis. there be no disease of the mucous membrane, in the beginning of the crisis there is hyperchlorhydria; but in case the crisis is prolonged or is repeated after short intervals, the vomit contains less and less HCl and ferments. such circumstances gastric secretion is normal during the intervals. But it is the rule, as a result of the antisyphilitic or antitabetic medication, to find chronic asthenic gastritis already present. The quantity of hydrochloric acid in the vomit in the beginning of the attack displays the secretory power of the diseased mucous membrane, and the acid is consequently diminished. During the course of the attack the acidity becomes less, and the diminution is due in part to the reflux of the duodenal contents into the stomach, and to the capillary hemorrhage which occurs in some of the very severe attacks. There seems never to be continuous secretion, nor is there myasthenia with retention or accumulation of the secretion of the stomach. Medication has no appreciable effect in the control or prevention of the crisis. It will be seen at a glance how different are the functional signs of the gastric crises of locomotor ataxia from those of chronic hypersthenic gastritis or from the paroxysmal form of hyperchylia gastrica, the two diseases with which the gastric crises are most likely to be confounded.

VIII. CEREBRAL DISEASES.

Meningitis, particularly basilar meningitis,-cerebral hemorrhages, brain abscess, and brain tumor, may be manifested by vomiting. The vomiting, which has the peculiar characteristics of cerebral vomiting, is central and symptomatic, and can not be properly considered a secondary affection of the stomach. Cerebral vomiting is easy, projectile, without rela

tion to meals or to the quality of the diet, is not accompanied by disease of the stomach, and may occur in crises. In every case of obstinate vomiting it should be a rule to look for possible cerebral lesions and their other manifestationsvertigo, headache, motor and sensory disturbances, and changes of the optic disc and retina. Brain injury has been known to produce capillary gastric hemorrhage. Hyperchlorhydria is more frequent in melancholia, in dementia paralytica, in mania, and in paranoia than is normal secretion, though hypochlorhydria is also found. Cerebral fatigue may produce paroxysmal hyperchylia gastrica, but the most common gastric affection which originates in the central nervous system is neurasthenia gastrica.

It is very difficult to define and explain the gastric troubles of neurasthenia. It may be contended that the disease of the stomach is only an accidental association, be it a dynamic affection or an anatomical disease. It may be contended that the gastric trouble is primary, and that it is the cause of the central neurasthenia. All the hypersthenic diseases of the stomach may produce general neurasthenia, and in latent forms may, during a variable length of time, be manifested by weakness and increased irritability of the central nervous system, even without subjective gastric symptoms. It may be contended, and sometimes with truth, that the central neurasthenia is primary, and that it may produce functional disturbances of the stomach, which in their normal evolution may become transformed into anatomical diseases. It seems wisest, in the prevailing confusion, to avoid partizan theories. If we have found in our experience that about one-third of the cases of central neurasthenia develop secondary affections of the stomach, and that about four-fifths of the cases of neurasthenia gastrica (primary) develop some of the signs and symptoms of cerebral and spinal neurasthenia, the observation may be imputed to the supposed tendency of each specialist to exaggerate the importance and the pathogenic influence of the organs whose diseases it is his particular business to treat. This This personal equation may be very great, and we admit its influence; but we should be more inclined to accept the neurologist's opinion if it were more frequently the custom to examine the stomach by the modern methods. In our experience, the most common secondary disease of the stomach in cerebrospinal neurasthenia is neurasthenia gastrica. There may be no abnormality of secretion or of the motor function-the patients simply suffer and complain, and are overanxious as a result of the sensations which accompany digestive activity,

just as in primary neurasthenia gastrica. At times there may be hyperchlorhydria-free HCl may appear too early in the course of the digestion of the test-breakfast, or it may be too great at the height of its digestion, or the appearance of free HCI may be delayed and, eventually, become excessive in quantity. More infrequently there may be hypochlorhydria. Or there may be myasthenia with a mild degree of stagnation, the stomach doing its motor work perfectly for a certain period, and then becoming insufficient, as may be clearly shown by the water-test. But the functional abnormality is intermittent and inconstant, for if the central neurasthenia be accompanied by a secretory disorder of a fixed chemical type, an organic change in the mucous membrane is present. The anatomical disease may be an accidental association, or it may have developed in consequence of the predisposition created by the neurasthenia and by the neurasthenic functional disorder.

The secondary affections of the stomach produced by hysteria are more numerous than those of neurasthenia. The most important are anorexia, hyperesthesia gastrica, anesthesia gastrica, and hysterical vomiting. These hysterical gastric troubles may be the only manifestations of the hysteria, or the psychosis may affect some of the voluntary and conscious functions of the organism. The monosymptomatic gastric form may present great difficulty in diagnosis. Although hysterical stigmata may be absent, the gastric affection may possess some peculiar and suggestive characteristic. The anorexia may be an anorexia with a fixed idea or purpose. The vomiting is always alimentary and easy. In spite of both anorexia and vomiting, nutrition may be perfectly preserved for a long time, and there is no organic disease of the stomach present to cause them. These affections begin suddenly and without an apparent cause, and end suddenly and in an inexplicable manner. They have no relation to the quality or quantity of the diet, and often run their course irregularly and in a manner typical of no particular disease of the stomach, and in total disregard of all, except suggestive treatment. These and many other well-known hysterical characteristics may suggest the nature of the puzzling and grotesque affection.

IX. DISEASES OF THE MOUTH, NOSE, AND THROAT. It is exceedingly difficult to determine the relation of the diseases of the mouth, nose, and throat to the diseases of the

stomach. In the first chapter of the Vicious Circles of the Stomach no mention was made of the possible causation of diseases of the upper air-passages by the diseases of the stomach, because such a result seems to be very infrequent. Acid regurgitation may affect the throat as it does the esoph agus, and the diseases of the stomach may influence the circulation, the nutrition, the nervous system, etc., in such a manner as to predispose more or less all the mucous membranes of the body to inflammation. That is about as much as can safely be said without danger of exaggeration. The autotoxic sore throats due to HS poisoning are of intestinal origin.

Diseases of the mouth may disturb gastric digestion by interfering with mastication or by changing the reaction and composition of the mixed secretion of the mouth; and thrush may, under fit circumstances, extend from the mouth to the stomach.

It is often contended that the frequent coexistence of nose and throat disease with gastric disease demonstrates that one or the other disease is secondary. But the two may be produced by the same cause, or they may be the effects of different causes. It is hard to find a perfectly normal nose and throat in New York, but diseases of the stomach are by no means so frequent, and in fine climates and in better hygienic surroundings the two classes of diseases are far less frequently associated.

Diseases of the nose and throat may influence the stomach by reflex action, by local irritation, by infection, or, in some cases, by the influence on the general health. After tabulating a large number of cases, we are unable to detect the reality of the reflex pathogenic influence on the stomach. There is no disturbance of secretion or of the motor function, which appears with regularity in connection with diseases of the rhinopharynx. The swallowing of large quantities of mucopus for a long period does affect the stomach, and the pyogenic cocci may grow on the mucous membrane if there be but little HCl secreted; such, anyway, would seem to be the case, as we have seen pyogenic cocci in large numbers on little pieces of the mucous membrane found in the expressed gastric contents. In chronic asthenic gastritis, associated with purulent rhinopharyngeal diseases, the micro-organisms of the stomach are a close reproduction of the micro-organisms which are swallowed. The tabulated cases show another noteworthy fact-the diseases of the stomach which are most frequent are associated with the most frequent diseases of the

rhinopharynx. While the etiological relation of the diseases of the stomach and the diseases of the throat, nose, and its accessory sinuses is still an open question, there can be no doubt that it should be the rule of practice to treat both diseases simultaneously.

X. DISEASES OF THE RESPIRATORY ORGANS.

Acute pleurisy produces no particular disturbance of the stomach, for the visceral congestion of its initial period is but slight, and the fever does not run high. Large effusions may interfere with the aëration and circulation of the blood, and with the movements of the diaphragm, which facilitate the circulation in the abdomen by subjecting the organs to rhythmical compression. But gastric digestion proceeds in a normal manner if proper attention be given to the diet, though reflex vomiting sometimes occurs, and the pleuritic pain, as does all severe pain, may depress the functions of the stomach. The disturbance of gastric digestion, if it occurs, passes away in a short time without doing any particular damage. Such is not the case, however, with empyema, for the toxemia depresses secretion, induces myasthenia, and sometimes leaves chronic asthenic gastritis as a legacy.

Acute bronchitis affects the stomach to a greater degree than does acute pleurisy. It appears that acute gastric catarrh with hyperchlorhydria, which is the common disturbance of the stomach in acute bronchitis, is only an associated disease due to a common cause. Chronic bronchitis and emphysema produce chronic defective aëration of the blood and dilatation of the right side of the heart. Passive congestion and catarrh of the stomach may result, and the swallowing of the expectoration of putrid bronchitis may disturb secretion and irritate the mucous membrane.

Pneumonia affects the stomach very seriously, and lobar pneumonia is more active in this respect than is the lobular form. Obstinate reflex vomiting may occur from the irritation of the pneumogastric by the compression of the consolidated lung, and it often follows the cough. The prolonged chill, high fever, defective aëration of the blood, and the insufficiency of the right side of the heart produce the most common disease of the stomach in pneumonia, which is acute gastritis. The gastritis may develop during the onset of the pneumonia, but it often appears later, when the heart insufficiency and cyanosis are most marked. The initial gastritis is accompanied by hyperchlorhydria (vomit of 17 cases), but the